p35-40w20_A&S Template 13/01/2012 16:24 Page 35

Art &science

If you would like to contribute to the Art & science

section, email gwen.clarke@rcnpublishing.co.uk

The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON

Auditing urinary catheter care

Dailly S (2012) Auditing urinary catheter care.
Nursing Standard. 26, 20, 35-40. Date of acceptance: May 6 2011.

Abstract
Urinary catheters are the main cause of hospital-acquired urinary
tract infections among inpatients. Healthcare staff can reduce the
risk of patients developing an infection by ensuring they give
evidence-based care and by removing the catheter as soon as it is
no longer necessary. An audit conducted in a Hampshire hospital
demonstrated there was poor documented evidence that best
practice was being carried out. Therefore a urinary catheter
assessment and monitoring tool was designed to promote best
practice and produce clear evidence that care had been provided.

Author
Sue Dailly
Lead nurse infection prevention and control, Royal Hampshire
County Hospital, Winchester.

Keywords
Audit, infection prevention and control, urinary tract infections

Review
All articles are subject to external double-blind peer review
and checked for plagiarism using automated software.

Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the
archive and search using the keywords above.

NATIONALLY, APPROXIMATELY 20% of all

hospital-acquired infections are urinary tract
infections, with an estimated 80% of these being
linked to urinary catheters (Hospital Infection
Society 2007). The Third Prevalence Study of
Healthcare Associated Infections in Acute
Hospitals in England 2006 found that 31% of
hospital inpatients in England had a urinary
catheter in situ at the time of the survey or within
the previous seven days (Hospital Infection
Society 2007). A hospital-acquired infection

NURSINGSTANDARD / RCNPUBLISHING

means the patient did not have any signs or

symptoms of this infection before admission and
the infection occurred after being in hospital for at
least 48 hours (Weston 2008). It has been estimated
that the risk of bacteriuria in catheterised patients
increases by 3-10% per day every day the catheter
remains in situ (Warren 1997), and 50% of patients
with a catheter in place for ten days will have a
bacteriuria (Saint and Chenoweth 2003). Patients
who develop a hospital-acquired infection can
expect to remain in hospital two and a half times
longer, and incur higher hospital and community
costs, than non-infected patients (Plowman 2000).
Indwelling urinary catheters are associated with
significant mortality and morbidity, and should
be avoided or used for the minimum time possible
(Saint and Chenoweth 2003). The greatest risk
factor for contracting a urinary tract infection is
having a urinary catheter; once inserted, the longer
the duration of catheterisation the greater the
risk of infection (Pellowe et al 2003). Therefore
using alternative urine collection strategies
when appropriate and reducing the duration
of catheterisation are critical in the prevention
of urinary tract infections.

Audit
The Department of Health began mandatory
reporting of meticillin-resistant Staphylococcus
aureus (MRSA) bacteraemias in April 2001. This
quickly demonstrated where serious infections
were occurring nationally and locally (Health
Protection Agency (HPA) 2009). The number
of cases nationally has reduced from 7,247 in
2001/02 (HPA et al 2005) to 1,898 in 2009/10
(HPA 2010). In 2008/09 the Royal Hampshire
County Hospital had five patients with MRSA
bacteraemias. Two were associated with urinary
catheters, of which one was a hospital-acquired
infection and the other a community-acquired
january 18 :: vol 26 no 20 :: 2012 35

p35-40w20_A&S Template 13/01/2012 16:24 Page 36

Art & science infection prevention

infection in a patient admitted from a nursing
home. The remaining three were caused by
wounds or other invasive devices. This focused
hospital staffs attention on urinary catheters as
being an important source of serious infection.
A root cause analysis was carried out on the two
MRSA bacteraemias linked to urinary catheters.
This is a multidisciplinary structured in-depth
investigation to identify how and why each of the
bacteraemias occurred. The patients doctor and
a senior nurse from the ward plus the infection
prevention and control nurses reviewed the notes
and ongoing care form, which revealed poor
quality documentation of the insertion and ongoing
care of both urinary catheters. The staff at the
meeting felt this was a common problem in the
hospital and a hospital-wide audit was carried out
to examine the quality of urinary catheter care.
Audits are used by infection prevention and
control teams to show that staff are carrying
out best practice, for example in urinary
catheterisation, and that procedures are being
followed correctly. Audit is a requirement of the
Health Act 2006: Code of Practice, which states
that NHS organisations must audit key policies
and procedures for infection prevention.
Designing an effective audit tool can be challenging
for staff. However, there are a large number of
audits already prepared that staff can use or adapt
to match local policy. Audit tools such as Saving
Lives (Department of Health 2007) now replaced
by the High Impact Interventions (Department of
Health 2011) and those published by the Infection
Prevention Society provide useful guidance.
The Royal Hampshire County Hospitals policy
is based on national evidence-based guidelines
(Pratt et al 2007). It therefore seemed appropriate
to use the Saving Lives care bundle on urinary
catheter care as the basis for the audit tool because
this reflects the epic2 guidelines. The Saving Lives
care bundle approach to urinary catheter insertion
and ongoing care lists the essential components or
steps required to insert and carry out ongoing
urinary catheter care. The risk of infection reduces
if all the elements of the care bundle are performed
for every patient every time. If one or more elements
of the care bundle is excluded or not undertaken,
then the patients risk of infection increases.
The aim is to observe practice, evaluate the
implementation of key elements of care, provide
feedback on the results and develop ideas for
improvement (Department of Health 2011).

Method
In June 2009 a hospital-wide urinary catheter
audit was undertaken which was divided into
four sections:
36 january 18 :: vol 26 no 20 :: 2012

4Observation of the insertion of urinary

catheters.
4Observation of emptying a urinary catheter bag.
4Prevalence study of patients with urinary
catheters and an audit of the documentation
of catheter insertion and ongoing care.
4Questions for staff to assess their knowledge
of urinary catheters and catheter-associated
urinary tract infections.
The infection prevention and control nurses
asked all healthcare staff to observe each others
practice and to record how someone inserts
a urinary catheter, rather than completing
a self-assessment form. This is because the
downside to self-assessment forms is that
staff may not be aware they are carrying
out care incorrectly or may not feel able to admit
this because they are embarrassed or fear the
consequences (Harvey 2002). Observed audit
provides proof that staff are compliant with
hospital standards and policies, although
consideration should be given to the Hawthorne
effect,where a member of staffs behaviour
changes because they are being observed
(Watson et al 2008).
Staff also carried out observations of ongoing
catheter care; this is often done by healthcare
assistants, while urinary catheter insertion tends
to be carried out by qualified nursing or medical
staff. Many different groups and grades of staff
took part in the audit.
A prevalence study involving a spot check was
used to identify how many patients had a catheter
in situ on a specific day, the reason for catheter
insertion and the quality of the documentation.
The three infection prevention and control nurses
divided the hospital between them and visited each
ward on one specific day.
A quiz was devised to ascertain from staff
what facts they knew about catheters and
urinary tract infections. Offering a prize draw
was helpful in motivating staff to do the quiz
rather than asking them to complete a
questionnaire as part of the audit.

Results
Four hundred patients on 22 wards took part in
the audit in June 2009. Nineteen per cent (n=76)
of the hospitals inpatients had a urinary catheter
in situ.
Urinary catheter insertion care bundle
For the audit of urinary catheter insertion, 85%
(n=65) of patients had all the key elements of the
care bundle performed (Figure 1). No catheter
insertions were observed on the labour or
maternity wards, only in surgery and medicine.

NURSINGSTANDARD / RCNPUBLISHING

p35-40w20_A&S Template 13/01/2012 16:24 Page 37

Staff knowledge quiz

Staff were well informed about urinary catheter
insertions and ongoing care, but reported that
they had not received any formal training
for several years. Although catheter care is
mentioned in an infection control annual update,
many staff requested a more formal training
session. Local ward-based sessions were
commenced for staff to attend.

FIGURE 1
Results for urinary catheter insertion (n=76)
100
80
60
40

Medicine

NURSINGSTANDARD / RCNPUBLISHING

Results for ongoing catheter care (n=76)

100
80
60
40

Medicine

Surgery

Handwashing
technique

Catheter still
required

Bag position

Patient
hygiene

Hand hygiene
after care

Apron

Gloves

20
Hand hygiene
before care

Percentage (%)

Family services

FIGURE 3
Results for documentation (n=76)
100
80

Medicine

Surgery

Job title

Name

Type

Length

Size

Time

40
20
0

Date

60

Reason

Documentation
The reason for catheter insertion was recorded
on average for 80% (n=61) of patients, but
documentation was often incomplete (Figure 3).
Usually the catheter packet sticker could be
located in the medical notes providing the date
of insertion. Sometimes the reason for insertion
was recorded with an illegible name and a bleep
number. Occasionally the word catheterise
was in a list of tasks to be completed with a tick
next to it.
The documentation for ongoing care was often
poor. The medical notes may mention catheter
still draining as part of the daily ward round.
Nursing notes were often no better; catheter
draining well may be the only reference to
show the patient still has a catheter in place.
The medical and nursing documentation was not
detailed enough to show whether or not the
Saving Lives care bundle had been complied
with. There was usually no mention of catheter
hygiene being carried out, whether the bag was
positioned off the floor or had been changed.

Surgery

FIGURE 2

Percentage (%)

Ongoing catheter care

For the audit of ongoing catheter care, 58%
(n=44) of patients received all aspects of care
outlined in the care bundle (Figure 2). The main
areas of non-compliance were:
4Not wearing an apron.
4No documentation that daily meatal hygiene
was being carried out.

Personal
protective
clothing

Hand
hygiene

Closed
system

Meatal
cleansing

Aseptic
technique

20
Lubricant
used

Percentage (%)

Areas of poor compliance with the standards

outlined in the care bundle were:
4Not wearing an apron because some staff
did not anticipate their uniform being
contaminated.
4Using chlorhexidine and cetrimide solution
instead of sodium chloride for meatal cleaning.
4Not always using a lubricant when
catheterising a female patient.
4Breaking the catheters closed system
prematurely. When a catheter is inserted and
the first bag is attached, a closed system is
formed. Each time the bag is changed it breaks
the closed system the more frequently this
occurs, the greater the risk of introducing
bacteria. The urinary catheter comes without
a bag attached, so staff have to decide which
type of bag is most appropriate for that
patients requirements. Most catheter bag
manufacturers recommend changing the bag
every five to seven days, so staff need to consider
whether the patient will be mobile in the next
few days and if so whether a leg bag be
attached. An hourly monitoring bag should be
used if accurate urine measurement is crucial.

Family services

january 18 :: vol 26 no 20 :: 2012 37

p35-40w20_A&S Template 13/01/2012 16:24 Page 38

Art & science infection prevention

Summary of audit results
The 2009 urinary catheter audit showed:
4Poor compliance with the use of aprons.
4Poor compliance with documentation
on catheter insertion and ongoing care.
4Delayed removal of catheters and confusion
over responsibility for their removal.

Dissemination of results
Prompt feedback of results and action planning
in teams is a crucial part of the audit cycle and
promotes local ownership to support effective
changes (Chambers and Wakley 2005). The
infection prevention and control nurses
disseminated the results to the weekly nursing
quality indicator meeting so that ward-based
staff were aware and had an opportunity to
discuss what they could do in their clinical areas
to make improvements. The results were
discussed at divisional meetings and the infection
prevention and control committee. One infection
prevention and control nurse also attended the
medical staffs meeting to present the results. The
interactive discussion between the consultants
enabled stroke physicians to explain why leaving
urinary catheters in place longer than necessary
caused long-term problems for patients.
Interestingly, few of the doctors present, apart
from those working in the care of older people,
reviewed whether urinary catheters should be
removed on their ward rounds; however, they did
review whether central venous catheters should
be removed. There seemed to be an assumption
that nurses would make the decision when to
remove a urinary catheter, and yet it had often
been inserted for medical reasons. The meeting
highlighted to a large group of doctors that the
removal of a urinary catheter needs to be
reviewed on every ward round.
The infection prevention and control nurse
monthly newsletter provided a summary of the
audit and recommendations for improvements
in practice. This newsletter goes out to all hospital
employees and is a useful way to share important
information with staff.

Action plan
The infection prevention and control nurses
began ward-based education sessions to
highlight the results of the audit and discuss
with staff how improvements could be made.
The main issue was how to tackle the problem
of poor documentation. If staff are not aware of
the reason why the catheter was inserted, how
can they decide when to remove it? The hospital
staff had been using a Visual Infusion Phlebitis
38 january 18 :: vol 26 no 20 :: 2012

(VIP) score form, which is based on Jacksons

(1998) work on intravenous cannula care.
The introduction of the form had improved
compliance with documentation on the insertion
and ongoing care of intravenous cannulae
significantly, but more importantly it had also
promoted prompt intravenous cannula removal.
The infection prevention and control nurses
therefore designed a urinary catheter assessment
and monitoring (UCAM) form for urinary
catheter insertion and ongoing care based on the
VIP score form. It included the Saving Lives care
bundle for insertion and ongoing care. It was A4
in size, had space for the identification sticker
from the packet the catheter comes in and
included the question for each day is the catheter
still required?. It was piloted on several wards to
get feedback from staff who would be using the
new form.
Feedback from the pilot was mixed and
included positive and negative comments, such as
seems like a good idea and not another piece of
paper, but the most common response we had
was that it was similar to the VIP form. This is
probably because VIP score charts had been used
successfully for some time, so having a similar form
for urinary catheters seemed acceptable to staff.
As a result of the pilot, some of the wording
and layout of the UCAM form was changed to
incorporate staff feedback. By September 2009
the UCAM form was introduced on the wards.
The forms were pre-printed in pads of 50 at
a cost of 2.38 per pad.

Follow-up audits
Having introduced the new form, it was
important to assess whether the quality of the
documentation on insertion and ongoing care of
urinary catheters had improved and whether the
UCAM form was promoting prompt catheter
removal. The infection prevention and control
nurses carried out two spot checks, one in
December 2009 and one in January 2010.
In December 2009, 21% of patients in the
hospital (66 out of 311 patients) had catheters
in place, and 23% (70 out of 303 patients) had
catheters in January 2010.
While carrying out the spot checks it became
apparent that there was a significant difference
in the number of patients who had catheters
inserted depending on which day of the week the
prevalence study was carried out. On Monday
there were no gynaecology patients with
catheters and few surgical and orthopaedic
patients. By Wednesday, more patients had
catheters inserted as a requirement of their
surgical procedure. However, counting the

NURSINGSTANDARD / RCNPUBLISHING

p35-40w20_A&S Template 13/01/2012 16:24 Page 39

number of catheters in situ was not going

to demonstrate an improvement in the quality
of patient care. The audit of UCAM
effectiveness needed to focus on aspects such as
documentation of the reason for urinary catheter
insertion, with evidence that a bladder scan had
been carried out before catheter insertion. Daily
recording on an UCAM form that the patient had
received meatal hygiene and that the catheter bag
had been checked and was positioned off the
floor demonstrated compliance with the care
bundle. The infection prevention and control
nurses were specifically interested in observing
whether the catheter was removed on the same
day if the answer to the question on the form is
the catheter still required? was no.
Although 99% (n=69) of patients with a
urinary catheter had a UCAM form by January
2010, the documented information was often
incomplete. This was because staff appeared to
focus on completing the parts of the form they
thought were important rather than all of the
sections, as described below:
4Theatre and recovery staff were good at
documenting catheter insertion details and
ensured that no patient left recovery without
one of the forms being completed, even if the
person inserting the catheter did not complete
the paperwork. What mattered was that the
patient had the form, with the details of the
catheterisation and the name of the person
who inserted it.
4Staff in the emergency department were not
as good at using the forms and tended to
document catheter insertion in the emergency
department notes.
4On the surgical wards the UCAM form was
sometimes left at the back of the patients folder
with the surgical records, rather than being
moved to the front of the folder with the
observation chart and the VIP score form.
4Staff on several wards reviewed their UCAM
and VIP score forms when the daily observations
were carried out at 2pm to ensure the forms were
complete for the morning ward rounds.
4The most common and significant response was
that staff reported that the form prompted them
to ask each day is the catheter still required?.
Several healthcare assistants commented that the
form made them feel empowered to ask a nurse
or doctor if a patients catheter was still required.
From April 2010 compliance with the UCAM
form became one of the weekly audits carried
out on each ward. Five patients per ward with
a urinary catheter (this number could be lower
if fewer patients had catheters in place)
had their UCAM documentation audited. The
results are entered on an Excel spreadsheet so that

NURSINGSTANDARD / RCNPUBLISHING

staff on each ward could compare scores with

those of other wards. Staff from each ward
present their results at the hospitals weekly
quality indicator meeting. This provides an
opportunity for staff to discuss what changes
could take place on the wards and to inform staff
in the emergency department when the UCAM
form has not been completed before the patient
leaves the department.
In June 2010 it was decided to repeat the audit
over several weeks, but this time the focus was
on the use of the UCAM form. Of the 80 patients
audited, 90% (n=72) had a UCAM form;
67% (n=54) had the insertion details completed
those that were not complete did have the health
professionals name, date and reason for insertion
completed; 65% (n=52) had ongoing care details
completed; others had either missed a day or had
not signed a column on the form. The main reason
for poor compliance with ongoing care was that
the form was not at the end of the patients bed
with the observation chart and VIP form, but was
lost among the admission assessments or theatre
paperwork. Further work is therefore required
to ensure better compliance in completing the
UCAM form.

Outcomes
The audit showed significant improvement in the
quality of the documentation for insertion and
ongoing care following the introduction of the
UCAM form. Most of the essential information,
such as the reason for insertion, was recorded on
the form, which was easily located at the end of
the patients bed. Ongoing care was documented
providing clear evidence of meatal hygiene and
catheter bag changes. Staff reported that they are
prompted to remove the catheter and more junior
staff stated that they feel empowered to ask
medical staff if the catheter is still required.
Consequently, the weekly quality audits show
that on average 194 catheters per month are
audited with only one or two per month deemed
unnecessary, which are removed following the
audit. The use of catheters for some surgical
procedures is now being challenged and
intermittent catheterisation is being used for
enhanced recovery orthopaedic procedures. No
MRSA bacteraemias have been linked to urinary
catheters since September 2009.
The UCAM form was included as one of the high
impact actions for nursing and midwifery in The
Essential Collection (NHS Institute for Innovation
and Improvement 2010). This is a collection of
innovations and changes introduced by nurses that
have made improvements to the quality of patient
care. The infection prevention and control nurses
january 18 :: vol 26 no 20 :: 2012 39

p35-40w20_A&S Template 13/01/2012 16:24 Page 40

Art & science infection prevention

and staff from the hospital were interviewed as
part of the project. Copies of the UCAM form
can be found on the NHS Institute for
Innovation and Improvement website
(http://tiny.cc/UCAM_form).
The infection prevention and control nurses
found that the UCAM form not only improved
documentation but also prompted timely removal
of urinary catheters. As the greatest risk for
acquiring a urinary tract infection is having a
catheter and, once inserted, the greatest risk
factor is the duration of catheterisation, the
prompt removal of a catheter will reduce a
patients risk of developing a catheter-associated
urinary tract infection as well as the associated
personal and financial effects that this type of
infection can have.

demonstrated this was a hospital-wide problem.

A UCAM form was developed that has provided
staff with a single form on which all information
linked to urinary catheter insertion and ongoing
care can be recorded. It also prompts staff to
adhere to best practice and, more importantly,
provides documented evidence that the care
has been carried out. Weekly audits on
compliance with the UCAM form and
documentation of whether the catheter is still
required provide ongoing evidence that the
hospital has improved the quality of patient
care relating to urinary catheters NS

USEFULRESOURCES
4Health Protection Agency
www.hpa.org.uk

Conclusion

4Infection Prevention Society

Examination of two MRSA bacteraemias at the

Royal Hampshire County Hospital revealed poor
documentation of insertion and care of urinary
catheters. An audit was carried out that

www.ips.uk.net

4NHS Institute for Innovations and Improvement

www.institute.nhs.uk

References
Chambers R, Wakley G (2005)
Clinical Audit in Primary Care:
Demonstrating Quality and Outcomes.
Radcliffe Publishing, Milton Keynes.
Department of Health (2007)
Saving Lives: Reducing Infection,
Delivering Clean and Safe Care.
The Stationery Office, London.
Department of Health (2011) High
Impact Interventions. http://hcai.dh.
gov.uk/whatdoido/high-impactinterventions (Last accessed:
December 19 2011.)
Harvey L (2002) Evaluation
for what? Teaching in Higher
Education. 7, 3, 245-263.
Health Protection Agency (2009)
Results of the First Three and a
Half Years of the Department
of Healths Mandatory Methicillin
Resistant Staphylococcus Aureus
(MRSA) Surveillance System

in Acute Trusts in England.

http://tiny.cc/HPA_MRSA (Last
accessed: December 19 2011.)
Health Protection Agency (2010)
Healthcare-Associated Infections
and Antimicrobial Resistance:
2009/10. http://bit.ly/tRuB2G
(Last accessed: December 19 2011.)
Health Protection Agency,
Communicable Disease Surveillance
Centre, Department of Health
(2005) MRSA Surveillance System:
Results. http://tiny.cc/DH_4085951
(Last accessed: December 19 2011.)
Hospital Infection Society (2007)
The Third Prevalence Survey of
Healthcare Associated Infections
in Acute Hospitals in England 2006.
The Stationery Office, London.
Jackson A (1998) Infection control
a battle in vein: infusion phlebitis.
Nursing Times. 94, 4, 68-71.

40 january 18 :: vol 26 no 20 :: 2012

NHS Institute for Innovation

and Improvement (2010) High
Impact Actions for Nursing
and Midwifery: The Essential
Collection. NHS Institute for
Innovation and Improvement,
Coventry.
Pellowe CM, Pratt RJ, Harper HP
et al (2003) Prevention of
healthcare-associated infections
in primary and community care.
Journal of Hospital Infection.
55, Suppl 2, S5-S127.
Plowman R (2000) The
socioeconomic burden of hospital
acquired infection. Eurosurveillance.
5, 4, 49-50.
Pratt RJ, Pellowe CM,
Wilson JA et al (2007) epic2:
National evidence-based guidelines
for preventing healthcareassociated infections in NHS
hospitals in England. Journal of

Hospital Infection. 65, Suppl 1,

S1-S64.
Saint S, Chenoweth CE (2003)
Biofilms and catheter-associated
urinary tract infections. Infectious
Disease Clinics of North America.
17, 2, 411-432.
Warren JW (1997)
Catheter-associated urinary tract
infections. Infectious Diseases
Clinics of North America. 11, 3,
609-622.
Watson R, McKenna H, Cowman S,
Keady J (2008) Nursing Research:
Designs and Methods.
Churchill Livingstone Elsevier,
Philadelphia PA.
Weston D (2008) Infection
Prevention and Control: Theory
and Practice for Healthcare
Professionals. John Wiley & Sons,
Chichester.

NURSINGSTANDARD / RCNPUBLISHING

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.